The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

The nurse waits 5 minutes between administering prescribed eye drops.

The nurse leaves the eye shield in place while the client sleeps.

The nurse is instructing the client not to drive at night.

The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Answer and Explanation

The Correct Answer is D

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Placing defibrillator pads and preparing for defibrillation is typically not indicated for supraventricular tachycardia (SVT) unless the patient is unresponsive or pulseless, which requires immediate emergency intervention. SVT is usually managed with vagal maneuvers or medications.

Choice B reason: Cardizem (diltiazem) is not administered subcutaneously. It is usually given orally or intravenously for the treatment of arrhythmias. Requesting clarification on this order is necessary to ensure the correct administration route.

Choice C reason: Preparing for synchronized cardioversion is an appropriate order for the treatment of unstable SVT if medications are ineffective. This procedure involves delivering a timed electrical shock to restore normal heart rhythm.

Choice D reason: Adenosine is not administered orally. It is typically given as a rapid intravenous push to treat SVT. Preparing adenosine for oral administration is incorrect and requires clarification to ensure the patient's safety and effective treatment.

Choice E reason: Preparing for adenosine IV is appropriate as it is the correct route of administration for treating SVT.

A. "I can change who serves as my health care proxy at any time." B. "The health care proxy does not go into effect until I am incapable of making decisions." C. "I have to choose a family member as my health proxy." D. "My health care proxy can make decisions on my behalf if I am unable to do so."

Correct Answer is C

Explanation

Choice A reason: The statement "I can change who serves as my health care proxy at any time" is correct. A client can modify or revoke their health care proxy designation as long as they are mentally competent.

Choice B reason: The statement "The health care proxy does not go into effect until I am incapable of making decisions" is accurate. The health care proxy is activated when the client is unable to make their own medical decisions.

Choice C reason: The statement "I have to choose a family member as my health proxy" indicates a need for clarification. A client is not required to choose a family member as their health care proxy; they can select any trusted individual to act in this capacity.

Choice D reason: The statement "My health care proxy can make decisions on my behalf if I am unable to do so" is correct. The purpose of a health care proxy is to appoint someone to make medical decisions when the client is incapacitated.

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The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the client exhibiting supraventricular tachycardia and calls the provider. Several orders are given. For which of the following orders would the nurse request further clarification? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which statement by the client indicates a need for clarification?

Correct Answer is C

Explanation

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